My Knee, part 2. Medicare Facts and Rumors

How much do you think a major New York City hospital charges per night for a bed,  in its 22-bed rehabilitation section, exclusive of professional services such as doctors, nurses, thereapists, etc.? Take a wild guess.

Anyone  say $7,100? If so, you are the winner. Unfortunately, there is no prize other than pride in being accurately cynical.

I know this figure to be true, because I received it today in a phone conversation with the assistant director, or maybe director, of  admissions at a major NYC Hospital with a rehab service.  It was in a conversation about why I would probably be sent to a nursing home for rehab after my knee replacement. Medicare, she said, will probably deny payment for me when they get the bill from the hospital because I am not 85, am having only an “uncomplicated, single-side” joint replacement have no other medical complications such as recent heart attack or stroke, and have no stairs in my home.

Knee replacement, by the way, was once described to me as having your leg cut off except for the ligaments and muscles and replacing the knee with titanium and plastic.  The recovery is reortedly long and painful. Call me crazy, but I feel as though I need a week afterwards, secure in the knowledge that there’s a doctor in the house, which is not the case in a nursing home.

So I canceled the surgery yesterday. Last night I got a call from the doctor (a first, actually) assuring me that it”s the surgery that matters, that rehab is ancillary, that the real work is after you get home and are in out-patient therapy, that the reality is that Medicare is broke (small wonder at $7,100 a night!), that if I go elsewhere and they botch the surgery, I can’t come to him for the repairs.

A few questions–If the surgery is primary and the rehab is ancillary, how come the surgery costs $2,000 and the rehab costs $7,100 a night, exclusive of professional services? I have more questions. But I have another doctor’s appointment (I’m limping along in the search for a new surgeon and a new hospital.) Meantime. memo to Senator Alan Simpson: It’s not the elderly who are sucking at the government tit; it’s the big hospitals—are any of their board members among your campaign donors?

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My Knee: Reflections on Medical Care in Our Time

Everything was going so well. I had gotten all my approvals for surgery. I had settled on the doctor who offered the earliest date—April 12. He told me, as he has on each of my previous two joint replacements (left and right hip) that there was no guarantee that I would be accepted into rehab. If I wasn’t, there was the option of going home with a big machine to bend my leg, pain killers, and the guarantee of Medicare-provided PT, visiting nurse, and home health aide, 6 days a week for about three weeks. But since I had been accepted the previous two times at the in-house rehab center, Rusk of the superlative reputation, and since knee replacement rehab is more painful and difficult than hip replacement rehab, I wasn’t worried.

My internist sent me for an echo cardiogram and a stress test, which I passed with flying colors—on the treadmill! no namby-pamby injections for  me. The eye doctor who’s been treating my blocked vein with an incredibly expensive medication also greenlighted me. I felt secure enough to cancel the tentative evaluation and later surgery date  with another surgeon at another hospital. He had in fact been my first choice, but he was out of town longer than the other guy, who had a cancellation that I decided to take, because it got the whole thing over with earlier, and I really didn’t want to think about it too much.

The next day (yesterday )I went to the hospital for all the pre-admission testing and instructions. That, too, went very well, though there was a curious tendency on the part of the admissions clerk and the nurse practitioner to make really silly jokes about anesthesia consisting of a block of wood and a bottle of vodka. I wondered if there had been a memo about lighthearted charm.

But three nurses double-checked my age because I didn’t look it, my blood pressure was back in 120/80 territory, I was charming, everyone was charming, and  the nurse practitioner whom I asked about the effects of the surgery assured me that I could get “110%” mobility back, provided I did all the exercises in the one to two weeks of rehab I might be approved for. I waxed semi-poetic about the quality of rehab at Rusk/HJD, and said it was a major reason for my choice of the hospital for going-on-3 surgeries. We beamed at each other.

Thenl I got home and got a call from another nurse at the hospital to discuss my “discharge plan.” That was when I found out that Rusk of the superlative reputation would not be available to me, a mere orthopedic-surgery patient, because Big Rusk on 34th St. had been seriously damaged by Sandy and now Rusk at the Hospital for Joint Diseases was fully occupied by stroke/brain damage patients transferred from Big Rusk. I went mildly postal (I did not have a gun). Why hadn’t my doctor or my doctor’s office or the hospital told me this in the past three weeks in any of our discussions of rehab??? My choices would now be a fairly small number of “acute” inpatient facilities, only two of which were in Manhattan, or some “subacute” facilities. I hung up.

Knee replacement, for those who don’t know, boils down to basically having your leg severed at the knee, except for theligaments and muscles, depending on the skill of the surgeon. It is not small time.

That night I framed a reasonable e-mail to my surgeon’s office, explaining the reasons why I felt I should be admmitted to inpatient rehab in an actual hospital. I mentioned the vision problems which had caused a lot of falls which had necessitated most of the joint replacements. I said I live alone and have an unfortunate tendency to fall. I said I might have to cancel the surgery.

I got a call back from the Scandinavian office manager—let us call her Brunhilde—whom I usually picture wearing a leather garter belt and wielding a whip. She said, in brief, that it was all Medicare’s fault, they’d changed the rules, and really I had to talk to them, and no, she had no idea what sort of language the “new rules”might be couched in, but if I wanted to cancel I should try to do so today, since there were others who would like the slot–which I knew wasn’t true, because I’d been told the doctor had only three surgeries scheduled that day, instead of the ten he does when business is good.

So I chortled inwardly and called Medicare, where a very helpful young woman in Virginia (whose grandmother had had a hip replacement recently) told me that the rules hadn’t changed, that Medicare covered inpatient rehab if the surgeon recommended it, and perhaps the problem was with the rehab facilities themselves. She had never heard of “subacute” rehab.

Back to Brunhilde, who said “that’s what Medicare says, but that’s not what happens.” Then on to the nurse from the day before. We both apologized to each other, she for being the bearer of bad news, I for losing my temper, and we began reviewing the options again. Guess what they call “subacute” rehab facilities??? Nursing homes with orthopedic rehab.I know about those. My mother was in one for four years during which I visited her 3 weekends out of 4. “Rehab” and “PT” mainly consisted of building up strength among the demented so they could get their spoons of gruel to their trembling lips, and working their legs enough so they could get to the toilet before they soiled their pajamas. You wouldn’t get me in one as a patient unless I were paralyzed and couldn’t run away.

So that’s wehre I am. Do I cancel the surgery next Friday until I can be assured of a real rehab facility? Or do I go through with it, hoping I will get sent to a hospital for rehab, but knowing my choices might be EITHER home alone with a machine and painkillers and various “helpers,” at least some of whom will know enough English to call 911 if I fall down (unlike the home health aide for my recently deceased neighbor, who had the misfortune to fall on her language-challenged watch), OR a stint in a nursing home where doctors drop in once or twice a week to okay the drugs that make the patients quiescent. Stay tuned. I haven’t decided.

By the way, as near as I can tell, between White Plalins and mmidtown Manhattan there are roughly 300 beds for acute inpatient rehab, most of which are dedicated to brain injuries and stroke .It’s so great to live in the greatest city in the best country in the world….